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Crash Cart Medication

The document provides information on medications commonly found in a crash cart or emergency trolley. It begins by outlining the purpose and general contents of crash carts, including oxygen, defibrillator, suction, blood pressure cuff, stethoscope, and emergency drug sheets. The contents of the cart's drawers are then described in more detail, focusing on medications for airway management, breathing support, IV supplies, IV fluids, cardiac procedures, and special procedures. Case scenarios are presented and specific medications - including adenosine, aspirin, nitroglycerin, morphine, clopidogrel, heparin, and amiodarone - are discussed in depth for each case.

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08/26/17 1 Crash Cart Medication Case scenario Dr. Sabah Awad Senior Specialist EM Al-Nahdah Hospital 2017
08/26/17 2 Objectives…. To train the health care provider on crash cart medications and their practice in common emergencies ( case oriented ). Mechanism of action Main indications Main contraindications Dosages Major side effect and precautions
The Crash Cart It is a multi drawer wheeled cabinet with the essential medication and tools that required in emergency situations. Other names: Emergency cart/Emergency response cart/Code cart/Emergency trolley PURPOSES: •To provide immediate access to supplies and medications. •To facilitate coordination of emergency equipment. •To ensure a properly stocked crash carts will be readily available. •To ensures a properly functioning defibrillator will be readily available. •To save the valuable time at the time of emergency . 3 .
08/26/17 4  Compromised Airway Respiratory Distress /Respiratory Arrest Cardiac Arrest /Abnormal cardiac rhythm Drug Overdose Hypoglycemia Anaphylactic Reaction
A/ Top of emergency trolley (External Contents) •Oxygen supply •Defibrillator with Monitor • Portable suction apparatus •Sphygmomanometer •Stethoscope •Emergency Crash Cart Check Sheet •Check List of cart contents. •Emergency drug information sheet 5
6 Contents of the trolley… B/Drawer contents (internal contents):  Drawer 1- Medications Drawer 2- Breathing and Airway Drawer 3- Circulation: IV supplies Drawer 4- Circulation: I.V. solutions and tubing Drawer 5- Cardiac, Chest Procedures Drawer 6- Special Procedure Trays
Contents of the trolley…. Drawer contents: Drawer 1- Medications 7
08/26/17 8 •Adenosine •Aspirin •Atropine Sulfate •Amiodarone •Calcium gluconate •Diphenhydramine •Diltiazem •Dextrose 50% ,25% •Epinephrine 1:10,000 •Epinephrine 1:1000 •Magnesium sulphate •Methylprednisolone •Metoprolol •Naloxone •Lidocaine •Procainamide •Sodium bicarbonate Analgesics -Fentanyl -Morphine Sedatives/Induction agents -Diazepam or midazolam -Propofol or Thiopentone -Ketamine Muscle relaxants -Non depolarising muscle relaxants – atracurium, rocuronium, vecuronium -Suxamethonium
08/26/17 9 Case scenario
08/26/17 10 Case No. 1 33 year old women presented to local health center with history of palpitation , dizziness , She denies any history of chest pain or SOB. Vital sign BP 135/75 , HR 160 /m, RR 16/m
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08/26/17 12 ADENOSINE CLASS Endogenous nucleoside, antidysrhythmic •Decreasing electrical conduction through the AV node without causing negative inotropic effects. •Decrease chronotropic activity by direct effect on sinus pacemaker cells and vagal nerve terminals . ONSET AND DURATION Onset: Immediate Duration: 10 sec. * INDICATIONS : First drug for most forms of narrow-complex paroxysmal SVT and Wolff-Parkinson-White (WPW) syndrome in adults and pediatric patients. *In undifferentiated regular stable wide-complex tachycardia, IV adenosine may be considered relatively safe. CONTRAINDICATIONS : •Second- or third-degree atrioventricular block •Hypersensitivity to adenosine. ADVERSE REACTIONS * Facial flushing ,Light-headedness , Paresthesias Headache, Diaphoresis,, Chest pain, Hypotension ,Transient periods of sinus bradycardia, sinus pause, or bradyasystole *
08/26/17 13 DRUG INTERACTIONS •Methylxanthines (e.g., caffeine and theophylline) antagonize the action of adenosine . •Dipyridamole , carbamazepine potentiates the effect of adenosine; reduction of adenosine dose may be required. DOSAGE AND ADMINISTRATION * •Adult: Initial dose: 6 mg rapid IV bolus over 1-3 sec, followed by a 20-mL saline bolus; then elevate extremity. A second dose (12 mg) may be given in 1-2 m in if needed. (need 2 nurses) •Pediatric: Initial dose 0.1 mg/kg IV/IO (max single dose: 6 mg); second dose 0.2 mg/kg IV/IO rapid push; followed with 5-10 ml NS flush * .
08/26/17 14 SPECIAL CONSIDERATIONS : •A brief period of asystole (up to 15 sec) following conversion, followed by resumption of normal sinus rhythm, is common after rapid administration.* •Reduce initial dose to 3 m g in patients receiving dipyridamole or carbamazepine, in heart transplant patients, or if given by central venous access. •Patients taking theophylline or caffeine may require larger doses of adenosine. •Deterioration (including hypotension) may result if given for irregular, polymorphic wide-complex tachycardia/ VT. •Adenosine may produce bronchoconstriction in patients with asthma and in patients with bronchopulmonary disease
Case no. 2 54 year old man known case of DM , HTN presented with history of Chest pain and syncopal episode at home . On presentation his complain SOB, chest tightness with two episodes of vomiting O.E : Conscious , looks sweaty , BP 110/65 HR 94/m regular, RR 22/m , O2 sat 93 %
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Oxygen Indications * Any suspected cardiopulmonary emergency * Critical illness conditions . * ACS , CVA Oxygen saturation less than 94 %* •Note: Pulse oximetry should be monitored Precautions…… Pulse oximetry inaccurate in: • Low cardiac output • Vasoconstriction • Hypothermia • Poisoning
08/26/17 18 Aspirin Platelet aggregation inhibitor, anti-inflammatory agent. Prevents platelets from clumping together, or aggregating, and forming emboli. Indications New onset chest pain suggestive of AMI or ACS. Contraindications Hypersensitivity*. Relatively contraindicated in patients with active ulcer disease or active asthma.* Adverse reactions/side effects Bronchospasm, anaphylaxis, wheezing in allergic patients, prolonged bleeding, GI bleeding, epigastric distress, nausea, vomiting, heartburn.
08/26/17 19 Drug interactions : Use with caution in patients allergic to NSAIDs . Dosage and administration : Adult: 160 mg to 325 mg PO. Chewing is preferable to swallowing. Pediatric: Not recommended. Onset: 30–45 minutes. Peak effect: Variable. Duration: Variable.
08/26/17 20 NITROGLYCERIN (GTN): Vasodilator Nitrates and nitrites dilate arterioles and veins in the periphery (and coronary arteries in high doses)* •Reduce preload, and to a lesser extent in afterload . •Decrease the workload of the heart . •Lower myocardial oxygen demand. Onset: 1-3 min, Duration: 30-60 min INDICATIONS : •Ischemic chest pain . •Congestive heart failure . •Hypertensive emergencies with ACS.
08/26/17 21 CONTRAINDICATIONS : Volume depletion , Hypersensitivity ,Hypotension Extreme bradycardia, Extreme tachycardia in the absence of heart failure, Right ventricular infarction ,Recent use of vardenafil (Levitra), or sildenafil (Viagra), Aortic stenosis. ADVERSE REACTIONS : Transient headache*, Reflex tachycardia ,Hypotension Nausea and vomiting, Postural syncope ,Diaphoresis . DRUG INTERACTIONS : Other vasodilators may have additive hypotensive effects. Do not mix with other drugs. DOSAGE AND ADMINISTRATION •Tablet: 0.4 mg sublingually; may repeat for a total of 3 doses at 5-min intervals. • Metered spray: 1-2 sprays (0.4m g/dose) for 0.5-1 sec. at 5-min intervals; max 3 sprays •Intravenous : start lower dose 0.5mg/h infusion increase it according to BP and patient complain .
08/26/17 22 MORPHINE SULFATE : Opioid analgesic •Has a primary effect of analgesia. •Decreases preload , afterload and decreases venous return •Euphoria . •Respiratory , central nervous system depression. Onset: 1-2 min after administration Duration: 2-7 Hr INDICATIONS :Chest pain associated with ACS unresponsive to nitrates Acute carcinogenic pulmonary edema* (with adequate blood pressure), severe acute and chronic pain . CONTRAINDICATIONS : •Hypersensitivity to narcotics •Hypovolemia •Hypotension •Use with caution in RV infarction
08/26/17 23 ADVERSE REACTIONS Hypotension , Bradycardia ,Palpitations ,Syncope Facial flushing *, diaphoresis, pruritus, Respiratory depression, Euphoria Bronchospasm*,Dry mouth, Allergic reaction* DRUG INTERACTIONS •Central nervous system depressants may potentiate effects of morphine (respiratory depression, hypotension, sedation). •Phenothiazine may potentiate analgesia. DOSAGE AND ADMINISTRATION Adult: •STEMI: 2-4 mg IV; may give additional doses of 2-4 mg IV at 5- to 15-min intervals ; BP ? Monitoring •UA/NSTEMI: 1-5 mg IV only if symptoms not relieved by nitrates or if symptoms recur (use with caution) •Pain: 2-4 mg slow IV over 1-5 min every 5-30 min; titrated to effect Pediatric: 0.1 mg/kg dose IV .
08/26/17 24 SPECIAL CONSIDERATIONS •Not used for prolonged periods or in high doses at term; narcotics rapidly cross the placenta •Safety in neonates has not been established. •Use with caution in the elderly, asthma, central nervous system depression.
08/26/17 25 Clopidogrel (Plavix) Class Thienopyridine antiplatelet. Mechanism of action : Inhibits platelet aggregation by blocking activation of the glycoprotein IIb/IIIa complex Indications :ST elevation MI (STEMI), moderate- to high-risk non-ST elevation MI (NSTEMI), acute coronary syndrome, substitute for aspirin in patients unable to take aspirin.* Contraindications : Active GI bleeding, intracranial hemorrhage, known hypersensitivity. Adverse reactions/side effects Severe neutropenia, thrombotic thrombocytopenic purpura (TTP), GI hemorrhage, cerebral hemorrhage, angioedema, Stevens-Johnson syndrome Dosage and administration Adult: Loading dose of 300–600 mg PO.* Onset: Rapid. Peak effect: 1 hour. Duration: 7–10 days.
08/26/17 26 Heparin Sodium Class Anticoagulant. Mechanism of action Prevents conversion of fibrogen to fibrin. Does not lyse existing clots. Indications AMI , prophylaxis and treatment of thromboembolic disorders . Contraindications Hypersensitivity, active bleeding, recent intracranial, intraspinal, or eye surgery, bleeding tendencies, severe thrombocytopenia. Adverse reactions/side effects Pain, anaphylaxis, shock, hematuria, GI bleeding, hemorrhage, thrombocytopenia, bruising. Drug interactions Salicylates, ibuprofen, dipyridamole, may increase risk of bleeding. Dosage and administration Adult: If used with fibrinolytic therapy,. Heparin is given as an IV bolus of 60 U/kg max 4,000 IU (weight adjusted). A continuous infusion is given following the bolus at a rate of 12 IU/kg/h Onset: IV Immediate, (SQ) 20–60 minutes. Peak effect: Variable. Duration: 4–8 hours.
08/26/17 27 RETEPLASE : CLASS Fibrinolytic A recombinant plasminogen activator. generating plasmin which degrades the fibrin matrix of a thrombus. Indication : STEMI to improve ventricular function following AMI. Onset: Causes reperfusion within 90 min for most patients Duration: Variable should administer within 30 from patient arrival to ED CONTRAINDICATIONS * Active internal bleeding, History of stroke, Recent intracranial or intraspinal surgery or trauma, Intracranial neoplasm, atrioventricular malformation, or aneurysm, Bleeding disorders ,Severe uncontrolled hypertension ADVERSE REACTIONS Bleeding (internal and at superficial sites),Reperfusion dysrhythmias, Allergic reaction (rare), Nausea ,vomiting, Hypotension DRUG INTERACTIONS. Risk of bleeding with concomitant use of heparin, vitamin K antagonist (e.g., warfarin) is greatly increased. Reteplase is incompatible with heparin; do not administer in the same IV line
08/26/17 28 DOSAGE AND ADMINISTRATION : 10 units as IV bolus over 2min. ,A second 10-unit IV bolus in 30 min. (Give NS flush before and after each bolus.) Heparin and aspirin should be administered concomitantly. SPECIAL CONSIDERATIONS •Reteplase should be given in an IV line in which no other medication is being injected or infused simultaneously. •Protect contents of package from light.
48 year old man admitted to the ER with chest pain, dyspnea, and palpitation . He appears in acute distress Vital signs are: HR 190/m , RR = 24, BP = 80/40 Oxygen sat. 92% Case No. 3
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08/26/17 31 Amiodarone Class Antidysrhythmic. Mechanism of action Blocks sodium and potassium channels delaying repolarization and increasing the duration of action potential. Indications : VF ,pulseless VT, unstable ventricular tachycardia in patients refractory to cardioversion . Contraindications : Known hypersensitivity to amiodarone or iodine, cardiogenic shock, sinus bradycardia, second- or third degree AV block. Adverse reactions/side effects Dizziness, fatigue, malaise, tremor, ataxia, lack of coordination, adult respiratory distress syndrome, progressive dyspnea, bradycardia, hypotension, worsening of dysrhythmias, prolonged QT interval, nausea, vomiting, burning at IV site . Drug interactions •Use with digoxin may cause digitalis toxicity. •Beta blocker and calcium channel blockers may potentiate bradycardia, sinus arrest, and AV heart blocks
08/26/17 32 Dosage and administration Adult •VF /pulseless VT: 300 mg IV/IO push. Initial dose can be followed one time in 3– 5 minutes at 150 mg IV/IO push. •Recurrent life-threatening ventricular dysrhythmias: Rapid infusion: 150 mg IV/IO over 10 minutes (15 mg/minute). May repeat rapid infusion (150 mg IV/IO) every 10 minutes as needed. Maximum cumulative dose: 2.2 g IV/24 h Pediatric: 5 mg/kg IV/IO bolus. Can repeat the 5 mg/kg IV/IO bolus up to a total dose of 15 mg/kg per 24 h. Maximum single dose: 300 mg. Onset: Immediate. Peak effect: 10–15 minutes. Duration: 30–45 minutes. Special considerations : •Monitor patient for hypotension. •May worsen or precipitate new dysrhythmias
08/26/17 33 Lidocaine Hydrochloride (Xylocaine) Class Antidysrhythmic. Mechanism of action Decreases automaticity by slowing the rate of spontaneous phase 4 depolarization. Indications Alternative to amiodarone in cardiac arrest from VT, VF , stable wide complex tachycardia (poly- or monomorphic) with normal baseline QT interval. Contraindications Hypersensitivity, second- or third-degree AV block . Adverse reactions/side effects Anxiety, drowsiness, confusion, seizures, slurred speech, respiratory arrest, hypotension, bradycardia, dysrhythmias, cardiac arrest, AV block, nausea, vomiting. Drug interactions •Apnea induced with succinylcholine may be prolonged with high doses of lidocaine. •Cardiac depression may occur in conjunction with IV phenytoin. Procainamide may exacerbate CNS effect.
08/26/17 34 Dosage and administration •Cardiac arrest : Pulseless VT/VF : Initial dose: 1–1.5 mg/kg IV/IO. Repeat dose: 0.5–0.75 mg/kg IV/IO repeated in 5–10 minutes. Maximum total dose: 3 mg/kg. •Stable VT , wide VT of unknown etiology, significant ectopy: Dose range 0.5–0.75 mg/kg and up to 1–1.5 mg/kg. Repeat 0.5–0.75 mg/kg every 5–10 minutes.
08/26/17 35 Onset: 1–5 minutes. Peak effect: 5–10 minutes. Duration: Variable Special considerations : •Reduce maintenance infusion by 50% if patient is older than 70 years of age, has liver or renal disease, is in CHF, or is in shock. •Avoid lidocaine for reperfusion dysrhythmias after fibrinolytic therapy. •Cross-reactivity with other forms of local anesthetics.
08/26/17 36 Procainamide Hydrochloride Class Antidysrhythmic. Mechanism of action Suppresses phase 4 depolarization in normal ventricular muscle and Purkinje fibers, reducing ectopic pacemaker’s automaticity; suppresses intraventricular conduction Indications Stable monomorphic VT with normal QT interval, reentry SVT uncontrolled by vagal maneuvers and adenosine, atrial fibrillation with rapid ventricular rate in patients with Wolff-Parkinson-White syndrome. Contraindications Polymorphic VT , second- and third degree heart block , QT prolongation, digitalis toxicity, tricyclic antidepressant overdose. Adverse reactions/side effects Confusion, seizures, hypotension, bradycardia, reflex tachycardia, ventricular dysrhythmias, AV blocks, asystole, widening of PR, QRS, and Q-T intervals, nausea, vomiting.
08/26/17 37 Drug interactions Increases plasma levels of amiodarone and quinidine. Dosage and administration Adult: •Recurrent VF /pulseless VT : 20 mg/min •Other indications: 20 mg/min slow IV infusion • Stop if any one of the following occurs : •Dysrhythmia suppression. •Hypotension . •QRS widens by >50% of its pretreatment width, •Total dose of 17 mg/kg has been given. Pediatric: Loading dose 15 mg/kg IV/IO over 30–60 minutes.
08/26/17 38 Onset:10–30 minutes. Peak effect: Variable. Duration:3–6 hours. Special considerations •Potent vasodilation and negative inotropic effects. •Hypotension may occur with rapid infusion. •Administer cautiously to patients with cardiac, hepatic, or renal insufficiency; Reduce the dose •Administer cautiously to patients with asthma or digitalis- induced dysrhythmias.
08/26/17 39 MAGNESIUM SULFATE CLASS Electrolyte, anticonvulsant Blocks peripheral neuromuscular transmission by reducing acetylcholine release at the myoneural junction. Lead to reduces muscle contractions Onset: Immediate; Duration: 30 min INDICATIONS •Seizures of eclampsia (toxemia of pregnancy) •Polymorphic VT •Life-threatening ventricular dysrhythmias attributable to digitalis toxicity •Suspected hypomagnesemia •Status asthmatics not responsive to beta-adrenergic drugs CONTRAINDICATIONS Heart block or myocardial damage ADVERSE REACTIONS Facial flushing, Hypotension, Depressed reflexes* Hypothermia ,Reduced heart rate, Circulatory collapse, Respiratory depression*
08/26/17 40 DRUG INTERACTIONS •Serious changes in cardiac function may occur with cardiac glycosides (avoid excess magnesium administration). DOSAGE AND ADMINISTRATION Adult •Seizure activity associated with pregnancy : 1-4 g IV/10m; then 1g/h • Cardiac Arrest : 1–2 g IV/IO over 5 min. • Torsades w/pulse or Hypomagnesemia: 1–2g over 10-30 min IV/IO then 0.5gm –1gm/hr • Status Asthmatics : 1-2 g over 30m ,Repeat the dose on need Pediatric Status asthmaticus 25-50 mg/kg IV/IO (max 2 g) over 30 min
08/26/17 41 SPECIAL CONSIDERATIONS •It is recommended that the drug not be administered in the 2 h before delivery . •IV calcium gluconate or calcium chloride should be available as an antagonist to magnesium if needed •Convulsions may occur up to 48 hr after delivery, necessitating continued therapy. •Magnesium must be used with caution in patients with renal failure because it is cleared by the kidneys and can reach toxic levels easily in those patients.
Case no. 4 60 year old man known case of DM brought by family , History of vomiting ,poor oral intake O.E : looks confused and sweaty BP 110/60 , HR 100/m , RR 20/M , RBS 1mmol 08/26/17 42
08/26/17 43 Dextrose Class Carbohydrate, antihypoglycemic. Mechanism of action: Rapidly increases serum glucose levels. Short-term osmotic diuresis. Indications : •Hypoglycemia, •Altered level of consciousness, coma of unknown origin, seizure of unknown origin, • Hyperkalemia* Contraindications : Intracranial hemorrhage. Adverse reactions/side effects :Extravasation leads to tissue necrosis., pulmonary edema, hyperglycemia.
08/26/17 44 Duration of action : Onset: Less than 1 minute. Peak effect: Variable. Duration: Variable. Special considerations : •Administer thiamine prior to D 50 in known alcoholic patients. Drug interactions : Sodium bicarbonate, warfarin (Coumadin). Dosage and administration • Adult: 50 ml of 50% solution slow IV push. May be repeated as necessary. •Pediatric: 1 year and older; 4 ml /kg of a 25% solution slow IV/IO push. May be repeated as necessary. •Neonates and infants: 2-4 ml / kg of a 10% solution slow IV push*
08/26/17 45 Case no. 5 34 year old man known case of depression brought by EMS found unresponsive , Agitated . O.E Confused ,Irritable Dilated pupils, Dry skin BP 90/60 , HR 110/m, O2sat 95 %,RR10/m . Blood sugar 7 mmol /L
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08/26/17 47 Sodium Bicarbonate Class Systemic hydrogen ion buffer, alkalizing agent. Mechanism of action Buffers metabolic acidosis and lactic acid by reacting with hydrogen ions to form water and carbon dioxide Indications : •Tricyclic antidepressant, aspirin, and phenobarbital overdose. •Metabolic acidosis during cardiac arrest.* •Hyperkalemia .* •crush injuries. * Contraindications : Metabolic and respiratory alkalosis, hypokalemia. Adverse reactions/side effects : Hypernatremia, metabolic alkalosis, necrosis at injection site. Seizures, fluid retention, hypokalemia, electrolyte imbalance, sodium retention, peripheral edema. Drug interactions. •Decreases the effects of benzodiazepines, tricyclic antidepressants. •May deactivate sympathomimetic (dopamine, epinephrine, norepinephrine).
08/26/17 48 Dosage and administration •Adult: 1mEq/kg slow IV, IO push may repeat at 0.5 mEq/kg every 10 minutes. •Pediatric:1mEq/kg slow IV, IO push dilute in small children to 4.2% . Onset: Seconds. Peak effect: 1–2 minutes. Duration: 10 minutes
08/26/17 49 Special considerations •Repeat as needed in tricyclic antidepressant overdose until QRS narrows. •Must be used in conjunction with effective ventilation and chest compressions in cardiac arrest. •Avoid contact with other medications; may precipitate or inactivate them. •Always flush IV line well before and after injecting •Use with caution in patients with CHF and renal disease due to high sodium concentration. •Monitor patient closely for signs and symptoms of fluid overload.
Case no. 6 68-year-old woman presented to the ED with two days of progressive dizziness followed by syncope on the day of presentation. She denied chest pain or dyspnea. She had a history of subarachnoid hemorrhage and hypertension managed with diltiazem.
08/26/17 52 Atropine Sulfate Class Anticholinergic agent. Acts as a competitive antagonist of acetylcholine (ACh) at the muscarinic receptor Increases heart rate in life-threatening Brady dysrhythmias Indications Hemodynamically unstable bradycardia, organophosphate poisoning, nerve agent exposure, RSI in pediatrics, beta blocker or calcium channel blocker overdose. Not likely to be effective for type II second-degree or third degree block Contraindications : Tachycardia, hypersensitivity, narrow-angle glaucoma, hypothermic bradycardia Adverse reactions/side effects Drowsiness, confusion, headache, tachycardia, palpitations, dysrhythmias, nausea, vomiting, pupil dilation, dry mouth/nose/skin, blurred vision, urinary retention, constipation, flushed, hot, dry skin; paradoxical bradycardia when pushed too slowly or when given at low doses.
08/26/17 53 Drug interactions Effects enhanced by antihistamines, procainamide, quinidine, antipsychotics, benzodiazepines, and antidepressants. DOSE : • Symptomatic bradycardia 0.5 mg IV ,repeat every 5m maximum dose 3 mg. • Organophosphate poisoning: Extremely large doses may be needed. • Pediatric: : 0.02 mg/kg IV/IO Onset: Immediate. Peak effect: Rapid to 1–2 minutes. Duration: 2–6 Hr Special considerations • Moderate doses may cause pupillary dilation. • Paradoxical bradycardia can occur with doses lower than 0.1 mg.
08/26/17 54 Calcium Gluconate Class Electrolyte. Mechanism of action : Stabilizing the membranes of the cardiac cells •Counteracts the toxicity of hyperkalemia . •Reducing the likelihood of fibrillation Indications: Hyperkalemia, hypocalcemia, hypermagnesemia, beta blocker and calcium channel blocker overdose. Contraindications: Digitalis toxicity *,Hypercalcemia. Adverse reactions/side effects: Syncope, cardiac arrest, dysrhythmia, bradycardia, asystole ,N., V., metallic taste, tissue necrosis at injection site .
08/26/17 55 Drug interactions •May worsen dysrhythmias secondary to digitalis toxicity. •May antagonize the effects of calcium channel blockers. •Do not mix or infuse immediately before or after sodium bicarbonate without intervening flush. Dosage and administration Adult: 10-20ml of 10% calcium gluconate over 10 m. Pediatric: 0.6-1.2 ml/kg 10 % calcium gluconate over 10m . Onset: Immediate. Peak effect: Immediate. Duration: 30m- 2H Special considerations Do not administer by IM or SQ; causes significant tissue necrosis
08/26/17 56 Case no. 7 23 year old man brought by his family founded unresponsive ,cyanotic with shallow breathing vital sign : BP100/60 , PR 56 /m, RR 4/m , O2 sat. 85% RA
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08/26/17 58 Naloxone Hydrochloride Class Opioid antagonist, antidote. Mechanism of action Competitive inhibition at narcotic receptor sites. Reverses respiratory depression secondary to opiate drugs. Indications •Opiate overdose ; complete or partial reversal of central nervous system and respiratory depression induced by opioids, •Decreased level of consciousness and coma of unknown origin. Narcotic antagonist for the following: Morphine sulfate, Heroin, Hydromorphone ,Methadone, Meperidine , Fentanyl ,Oxycodone Codeine, Propoxyphene.
08/26/17 59 Special consideration • Use with caution in narcotic-dependent patients. * • Use with caution in neonates of narcotic-addicted mothers.* Adverse reactions/side effects Restlessness,* seizures*, dyspnea, pulmonary edema*, tachycardia, hypertension, dysrhythmias, nausea, vomiting, withdrawal symptoms in opioid-addicted patients, diaphoresis. Drug interactions Incompatible with bisulfite and alkaline solutions.
08/26/17 60 Dosage and administration Adult: 0.4–2 mg IM/IV/IO/SQ/ ET/Intranasal (diluted); minimum single dose* recommended. Repeat at 5-minute intervals to a maximum total dose of 10 mg. Pediatric: 0.1 mg/kg/dose IV/IO/IM/SQ every 2 minutes as needed. Maximum total dose of 2 mg. If no response in 10 minutes, administer an additional 0.1 mg/kg/dose. Onset: <2 minutes. Peak effect: Variable. Duration: 30–60 minutes. Special considerations : •Assist ventilations prior to administration to avoid sympathetic stimulation. •Use caution when administering to narcotic addicts (potential violent behavior). • Half-life of naloxone is often shorter than the half-life of narcotics; repeat dosing may be required.
08/26/17 61 DIAZEPAM CLASS Benzodiazepine Indication •Acute Anxiety States •Acute Alcohol Withdrawal •Skeletal Muscle Relaxation •Seizure Activity •Premedication Before Counter shock Or Transcutaneous Pacing Rapid IV administration may be followed by respiratory depression and excessive sedation, particularly in elderly patients. Onset: (IV) 1-5 min; (IM) 15-30 min Duration: (IV) 15 min-1Hr; (IM) 15min-1Hr
08/26/17 62 Contraindications •Hypersensitivity to the drug . •Substance abuse (use with caution) . •Coma (unless the patient has seizures or severe muscle rigidity or myoclonus) •Shock •Central nervous system depression as a result of head injury •Respiratory depression . ADVERSE REACTIONS :Hypotension, Respiratory depression , Ataxia, Confusion, Dizziness ,Drowsiness, Blurred vision DRUG INTERACTIONS •Increase CNS depression with other CNS depressant medications. •Incompatible with most fluids; should be administered into an IV of NS solution. .
08/26/17 63 DOSAGE AND ADMINISTRATION •Seizure Activity Adult: 5-10 mg over 2m. IV every 10-15 m in prn (max dose: 30 mg) Pediatric: 0.1 -0.2 mg /kg max 5 mg slow IV •Cardioversion or Transcutaneous Pacing Adult: 5-10 m g IV, over 2 min. before procedure SPECIAL CONSIDERATIONS : •Diazepam may cause local venous irritation. • Reduce dose by 50% in elderly patients. • Rectal administration may require higher dose because absorption is incomplete. • Resuscitation equipment should be readily available
08/26/17 64 Case no. 8 28 year old female brought by her family with history of bee sting at home . O.E puffy face, swollen lip and unable to swallow diffuse skin rash, wheezy chest BP 100/60 , HR 110/M , RR 22/M
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08/26/17 66 Epinephrine(Adrenalin) Class Sympathomimetic. Mechanism of action Direct-acting alpha and beta agonist. •Alpha: vasoconstriction. •Beta-1: positive inotropic, chronotropic, and dromotropic effects. •Beta-2: bronchial smooth muscle relaxation and dilation of skeletal vasculature. •Blocks histamine receptors. Indications •Cardiac arrest (asystole, PEA, VF and pulseless VT ), •Symptomatic bradycardia as an alternative infusion to dopamine, •Severe hypotension secondary to bradycardia when atropine and transcutaneous pacing are unsuccessful, •Allergic reaction, anaphylaxis, asthma. Contraindications : Hypertension, hypothermia, pulmonary edema, myocardial ischemia, hypovolemic shock.* Adverse reactions/side effects* Nervousness, restlessness, headache, tremor, pulmonary edema, dysrhythmias, chest pain, hypertension, tachycardia, N,V .
08/26/17 67 Drug interactions •Potentiates other sympathomimetics. •Deactivated by alkaline solutions. Dosage and administration Adult: •Anaphylaxis: 0.3 mg-0.5 mg* (1:1,000) IM repeat every 5-10 m . •Cardiac arrest: IV/IO dose: 1 mg (10 mL, 1:10,000 solution) 3–5 minutes during resuscitation. •Profound bradycardia or hypotension: 2–10 µg/min; titrate to patient response. •Higher dose: Higher doses (up to 0.2 mg/kg) may be used for specific indications: (beta blocker or calcium channel blocker overdose).
08/26/17 68 Pediatric: •Anaphylaxis/severe status asthmaticus: 0.01 mg/kg (0.01 mL/kg) IM of a 1:1,000 solution (maximum single dose: 0.3 mg). •Cardiac arrest: IV/IO dose: 0.01 mg/kg (0.1 mL/kg) of a 1:10,000 solution every 3–5 minutes during arrest. • Symptomatic bradycardia: IV/IO dose: 0.01 mg/kg (0.01 mL/kg) of a 1:10,000 solution. Onset: Immediate. Peak effect: Minutes. Duration : Several minutes. Special considerations •May cause syncope in asthmatic children. •May increase myocardial oxygen demand. To mix an infusion add 1 mg of epinephrine 1:1,000 to 500 mL D 5 W for a yield of 2 mcg/mL.
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CRITICAL POINTS • Know dosages, indications, contraindications and side effects of drugs . • Know concentrations of drugs. • Know what drugs look like at your organization • Read…Read…Read 08/26/17 71
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08/26/17 73 Thank you

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Crash Cart Medication

  • 1.
    08/26/17 1 Crash CartMedication Case scenario Dr. Sabah Awad Senior Specialist EM Al-Nahdah Hospital 2017
  • 2.
    08/26/17 2 Objectives…. To trainthe health care provider on crash cart medications and their practice in common emergencies ( case oriented ). Mechanism of action Main indications Main contraindications Dosages Major side effect and precautions
  • 3.
    The Crash Cart Itis a multi drawer wheeled cabinet with the essential medication and tools that required in emergency situations. Other names: Emergency cart/Emergency response cart/Code cart/Emergency trolley PURPOSES: •To provide immediate access to supplies and medications. •To facilitate coordination of emergency equipment. •To ensure a properly stocked crash carts will be readily available. •To ensures a properly functioning defibrillator will be readily available. •To save the valuable time at the time of emergency . 3 .
  • 4.
    08/26/17 4  CompromisedAirway Respiratory Distress /Respiratory Arrest Cardiac Arrest /Abnormal cardiac rhythm Drug Overdose Hypoglycemia Anaphylactic Reaction
  • 5.
    A/ Top ofemergency trolley (External Contents) •Oxygen supply •Defibrillator with Monitor • Portable suction apparatus •Sphygmomanometer •Stethoscope •Emergency Crash Cart Check Sheet •Check List of cart contents. •Emergency drug information sheet 5
  • 6.
    6 Contents of thetrolley… B/Drawer contents (internal contents):  Drawer 1- Medications Drawer 2- Breathing and Airway Drawer 3- Circulation: IV supplies Drawer 4- Circulation: I.V. solutions and tubing Drawer 5- Cardiac, Chest Procedures Drawer 6- Special Procedure Trays
  • 7.
    Contents of thetrolley…. Drawer contents: Drawer 1- Medications 7
  • 8.
    08/26/17 8 •Adenosine •Aspirin •Atropine Sulfate •Amiodarone •Calciumgluconate •Diphenhydramine •Diltiazem •Dextrose 50% ,25% •Epinephrine 1:10,000 •Epinephrine 1:1000 •Magnesium sulphate •Methylprednisolone •Metoprolol •Naloxone •Lidocaine •Procainamide •Sodium bicarbonate Analgesics -Fentanyl -Morphine Sedatives/Induction agents -Diazepam or midazolam -Propofol or Thiopentone -Ketamine Muscle relaxants -Non depolarising muscle relaxants – atracurium, rocuronium, vecuronium -Suxamethonium
  • 9.
  • 10.
    08/26/17 10 Case No.1 33 year old women presented to local health center with history of palpitation , dizziness , She denies any history of chest pain or SOB. Vital sign BP 135/75 , HR 160 /m, RR 16/m
  • 11.
  • 12.
    08/26/17 12 ADENOSINE CLASSEndogenous nucleoside, antidysrhythmic •Decreasing electrical conduction through the AV node without causing negative inotropic effects. •Decrease chronotropic activity by direct effect on sinus pacemaker cells and vagal nerve terminals . ONSET AND DURATION Onset: Immediate Duration: 10 sec. * INDICATIONS : First drug for most forms of narrow-complex paroxysmal SVT and Wolff-Parkinson-White (WPW) syndrome in adults and pediatric patients. *In undifferentiated regular stable wide-complex tachycardia, IV adenosine may be considered relatively safe. CONTRAINDICATIONS : •Second- or third-degree atrioventricular block •Hypersensitivity to adenosine. ADVERSE REACTIONS * Facial flushing ,Light-headedness , Paresthesias Headache, Diaphoresis,, Chest pain, Hypotension ,Transient periods of sinus bradycardia, sinus pause, or bradyasystole *
  • 13.
    08/26/17 13 DRUG INTERACTIONS •Methylxanthines(e.g., caffeine and theophylline) antagonize the action of adenosine . •Dipyridamole , carbamazepine potentiates the effect of adenosine; reduction of adenosine dose may be required. DOSAGE AND ADMINISTRATION * •Adult: Initial dose: 6 mg rapid IV bolus over 1-3 sec, followed by a 20-mL saline bolus; then elevate extremity. A second dose (12 mg) may be given in 1-2 m in if needed. (need 2 nurses) •Pediatric: Initial dose 0.1 mg/kg IV/IO (max single dose: 6 mg); second dose 0.2 mg/kg IV/IO rapid push; followed with 5-10 ml NS flush * .
  • 14.
    08/26/17 14 SPECIAL CONSIDERATIONS: •A brief period of asystole (up to 15 sec) following conversion, followed by resumption of normal sinus rhythm, is common after rapid administration.* •Reduce initial dose to 3 m g in patients receiving dipyridamole or carbamazepine, in heart transplant patients, or if given by central venous access. •Patients taking theophylline or caffeine may require larger doses of adenosine. •Deterioration (including hypotension) may result if given for irregular, polymorphic wide-complex tachycardia/ VT. •Adenosine may produce bronchoconstriction in patients with asthma and in patients with bronchopulmonary disease
  • 15.
    Case no. 2 54year old man known case of DM , HTN presented with history of Chest pain and syncopal episode at home . On presentation his complain SOB, chest tightness with two episodes of vomiting O.E : Conscious , looks sweaty , BP 110/65 HR 94/m regular, RR 22/m , O2 sat 93 %
  • 16.
  • 17.
    Oxygen Indications * Any suspectedcardiopulmonary emergency * Critical illness conditions . * ACS , CVA Oxygen saturation less than 94 %* •Note: Pulse oximetry should be monitored Precautions…… Pulse oximetry inaccurate in: • Low cardiac output • Vasoconstriction • Hypothermia • Poisoning
  • 18.
    08/26/17 18 Aspirin Platelet aggregationinhibitor, anti-inflammatory agent. Prevents platelets from clumping together, or aggregating, and forming emboli. Indications New onset chest pain suggestive of AMI or ACS. Contraindications Hypersensitivity*. Relatively contraindicated in patients with active ulcer disease or active asthma.* Adverse reactions/side effects Bronchospasm, anaphylaxis, wheezing in allergic patients, prolonged bleeding, GI bleeding, epigastric distress, nausea, vomiting, heartburn.
  • 19.
    08/26/17 19 Drug interactions: Use with caution in patients allergic to NSAIDs . Dosage and administration : Adult: 160 mg to 325 mg PO. Chewing is preferable to swallowing. Pediatric: Not recommended. Onset: 30–45 minutes. Peak effect: Variable. Duration: Variable.
  • 20.
    08/26/17 20 NITROGLYCERIN (GTN):Vasodilator Nitrates and nitrites dilate arterioles and veins in the periphery (and coronary arteries in high doses)* •Reduce preload, and to a lesser extent in afterload . •Decrease the workload of the heart . •Lower myocardial oxygen demand. Onset: 1-3 min, Duration: 30-60 min INDICATIONS : •Ischemic chest pain . •Congestive heart failure . •Hypertensive emergencies with ACS.
  • 21.
    08/26/17 21 CONTRAINDICATIONS :Volume depletion , Hypersensitivity ,Hypotension Extreme bradycardia, Extreme tachycardia in the absence of heart failure, Right ventricular infarction ,Recent use of vardenafil (Levitra), or sildenafil (Viagra), Aortic stenosis. ADVERSE REACTIONS : Transient headache*, Reflex tachycardia ,Hypotension Nausea and vomiting, Postural syncope ,Diaphoresis . DRUG INTERACTIONS : Other vasodilators may have additive hypotensive effects. Do not mix with other drugs. DOSAGE AND ADMINISTRATION •Tablet: 0.4 mg sublingually; may repeat for a total of 3 doses at 5-min intervals. • Metered spray: 1-2 sprays (0.4m g/dose) for 0.5-1 sec. at 5-min intervals; max 3 sprays •Intravenous : start lower dose 0.5mg/h infusion increase it according to BP and patient complain .
  • 22.
    08/26/17 22 MORPHINE SULFATE: Opioid analgesic •Has a primary effect of analgesia. •Decreases preload , afterload and decreases venous return •Euphoria . •Respiratory , central nervous system depression. Onset: 1-2 min after administration Duration: 2-7 Hr INDICATIONS :Chest pain associated with ACS unresponsive to nitrates Acute carcinogenic pulmonary edema* (with adequate blood pressure), severe acute and chronic pain . CONTRAINDICATIONS : •Hypersensitivity to narcotics •Hypovolemia •Hypotension •Use with caution in RV infarction
  • 23.
    08/26/17 23 ADVERSE REACTIONSHypotension , Bradycardia ,Palpitations ,Syncope Facial flushing *, diaphoresis, pruritus, Respiratory depression, Euphoria Bronchospasm*,Dry mouth, Allergic reaction* DRUG INTERACTIONS •Central nervous system depressants may potentiate effects of morphine (respiratory depression, hypotension, sedation). •Phenothiazine may potentiate analgesia. DOSAGE AND ADMINISTRATION Adult: •STEMI: 2-4 mg IV; may give additional doses of 2-4 mg IV at 5- to 15-min intervals ; BP ? Monitoring •UA/NSTEMI: 1-5 mg IV only if symptoms not relieved by nitrates or if symptoms recur (use with caution) •Pain: 2-4 mg slow IV over 1-5 min every 5-30 min; titrated to effect Pediatric: 0.1 mg/kg dose IV .
  • 24.
    08/26/17 24 SPECIAL CONSIDERATIONS •Notused for prolonged periods or in high doses at term; narcotics rapidly cross the placenta •Safety in neonates has not been established. •Use with caution in the elderly, asthma, central nervous system depression.
  • 25.
    08/26/17 25 Clopidogrel (Plavix)Class Thienopyridine antiplatelet. Mechanism of action : Inhibits platelet aggregation by blocking activation of the glycoprotein IIb/IIIa complex Indications :ST elevation MI (STEMI), moderate- to high-risk non-ST elevation MI (NSTEMI), acute coronary syndrome, substitute for aspirin in patients unable to take aspirin.* Contraindications : Active GI bleeding, intracranial hemorrhage, known hypersensitivity. Adverse reactions/side effects Severe neutropenia, thrombotic thrombocytopenic purpura (TTP), GI hemorrhage, cerebral hemorrhage, angioedema, Stevens-Johnson syndrome Dosage and administration Adult: Loading dose of 300–600 mg PO.* Onset: Rapid. Peak effect: 1 hour. Duration: 7–10 days.
  • 26.
    08/26/17 26 Heparin SodiumClass Anticoagulant. Mechanism of action Prevents conversion of fibrogen to fibrin. Does not lyse existing clots. Indications AMI , prophylaxis and treatment of thromboembolic disorders . Contraindications Hypersensitivity, active bleeding, recent intracranial, intraspinal, or eye surgery, bleeding tendencies, severe thrombocytopenia. Adverse reactions/side effects Pain, anaphylaxis, shock, hematuria, GI bleeding, hemorrhage, thrombocytopenia, bruising. Drug interactions Salicylates, ibuprofen, dipyridamole, may increase risk of bleeding. Dosage and administration Adult: If used with fibrinolytic therapy,. Heparin is given as an IV bolus of 60 U/kg max 4,000 IU (weight adjusted). A continuous infusion is given following the bolus at a rate of 12 IU/kg/h Onset: IV Immediate, (SQ) 20–60 minutes. Peak effect: Variable. Duration: 4–8 hours.
  • 27.
    08/26/17 27 RETEPLASE :CLASS Fibrinolytic A recombinant plasminogen activator. generating plasmin which degrades the fibrin matrix of a thrombus. Indication : STEMI to improve ventricular function following AMI. Onset: Causes reperfusion within 90 min for most patients Duration: Variable should administer within 30 from patient arrival to ED CONTRAINDICATIONS * Active internal bleeding, History of stroke, Recent intracranial or intraspinal surgery or trauma, Intracranial neoplasm, atrioventricular malformation, or aneurysm, Bleeding disorders ,Severe uncontrolled hypertension ADVERSE REACTIONS Bleeding (internal and at superficial sites),Reperfusion dysrhythmias, Allergic reaction (rare), Nausea ,vomiting, Hypotension DRUG INTERACTIONS. Risk of bleeding with concomitant use of heparin, vitamin K antagonist (e.g., warfarin) is greatly increased. Reteplase is incompatible with heparin; do not administer in the same IV line
  • 28.
    08/26/17 28 DOSAGE ANDADMINISTRATION : 10 units as IV bolus over 2min. ,A second 10-unit IV bolus in 30 min. (Give NS flush before and after each bolus.) Heparin and aspirin should be administered concomitantly. SPECIAL CONSIDERATIONS •Reteplase should be given in an IV line in which no other medication is being injected or infused simultaneously. •Protect contents of package from light.
  • 29.
    48 year oldman admitted to the ER with chest pain, dyspnea, and palpitation . He appears in acute distress Vital signs are: HR 190/m , RR = 24, BP = 80/40 Oxygen sat. 92% Case No. 3
  • 30.
  • 31.
    08/26/17 31 Amiodarone ClassAntidysrhythmic. Mechanism of action Blocks sodium and potassium channels delaying repolarization and increasing the duration of action potential. Indications : VF ,pulseless VT, unstable ventricular tachycardia in patients refractory to cardioversion . Contraindications : Known hypersensitivity to amiodarone or iodine, cardiogenic shock, sinus bradycardia, second- or third degree AV block. Adverse reactions/side effects Dizziness, fatigue, malaise, tremor, ataxia, lack of coordination, adult respiratory distress syndrome, progressive dyspnea, bradycardia, hypotension, worsening of dysrhythmias, prolonged QT interval, nausea, vomiting, burning at IV site . Drug interactions •Use with digoxin may cause digitalis toxicity. •Beta blocker and calcium channel blockers may potentiate bradycardia, sinus arrest, and AV heart blocks
  • 32.
    08/26/17 32 Dosage andadministration Adult •VF /pulseless VT: 300 mg IV/IO push. Initial dose can be followed one time in 3– 5 minutes at 150 mg IV/IO push. •Recurrent life-threatening ventricular dysrhythmias: Rapid infusion: 150 mg IV/IO over 10 minutes (15 mg/minute). May repeat rapid infusion (150 mg IV/IO) every 10 minutes as needed. Maximum cumulative dose: 2.2 g IV/24 h Pediatric: 5 mg/kg IV/IO bolus. Can repeat the 5 mg/kg IV/IO bolus up to a total dose of 15 mg/kg per 24 h. Maximum single dose: 300 mg. Onset: Immediate. Peak effect: 10–15 minutes. Duration: 30–45 minutes. Special considerations : •Monitor patient for hypotension. •May worsen or precipitate new dysrhythmias
  • 33.
    08/26/17 33 Lidocaine Hydrochloride(Xylocaine) Class Antidysrhythmic. Mechanism of action Decreases automaticity by slowing the rate of spontaneous phase 4 depolarization. Indications Alternative to amiodarone in cardiac arrest from VT, VF , stable wide complex tachycardia (poly- or monomorphic) with normal baseline QT interval. Contraindications Hypersensitivity, second- or third-degree AV block . Adverse reactions/side effects Anxiety, drowsiness, confusion, seizures, slurred speech, respiratory arrest, hypotension, bradycardia, dysrhythmias, cardiac arrest, AV block, nausea, vomiting. Drug interactions •Apnea induced with succinylcholine may be prolonged with high doses of lidocaine. •Cardiac depression may occur in conjunction with IV phenytoin. Procainamide may exacerbate CNS effect.
  • 34.
    08/26/17 34 Dosage andadministration •Cardiac arrest : Pulseless VT/VF : Initial dose: 1–1.5 mg/kg IV/IO. Repeat dose: 0.5–0.75 mg/kg IV/IO repeated in 5–10 minutes. Maximum total dose: 3 mg/kg. •Stable VT , wide VT of unknown etiology, significant ectopy: Dose range 0.5–0.75 mg/kg and up to 1–1.5 mg/kg. Repeat 0.5–0.75 mg/kg every 5–10 minutes.
  • 35.
    08/26/17 35 Onset: 1–5minutes. Peak effect: 5–10 minutes. Duration: Variable Special considerations : •Reduce maintenance infusion by 50% if patient is older than 70 years of age, has liver or renal disease, is in CHF, or is in shock. •Avoid lidocaine for reperfusion dysrhythmias after fibrinolytic therapy. •Cross-reactivity with other forms of local anesthetics.
  • 36.
    08/26/17 36 Procainamide HydrochlorideClass Antidysrhythmic. Mechanism of action Suppresses phase 4 depolarization in normal ventricular muscle and Purkinje fibers, reducing ectopic pacemaker’s automaticity; suppresses intraventricular conduction Indications Stable monomorphic VT with normal QT interval, reentry SVT uncontrolled by vagal maneuvers and adenosine, atrial fibrillation with rapid ventricular rate in patients with Wolff-Parkinson-White syndrome. Contraindications Polymorphic VT , second- and third degree heart block , QT prolongation, digitalis toxicity, tricyclic antidepressant overdose. Adverse reactions/side effects Confusion, seizures, hypotension, bradycardia, reflex tachycardia, ventricular dysrhythmias, AV blocks, asystole, widening of PR, QRS, and Q-T intervals, nausea, vomiting.
  • 37.
    08/26/17 37 Drug interactionsIncreases plasma levels of amiodarone and quinidine. Dosage and administration Adult: •Recurrent VF /pulseless VT : 20 mg/min •Other indications: 20 mg/min slow IV infusion • Stop if any one of the following occurs : •Dysrhythmia suppression. •Hypotension . •QRS widens by >50% of its pretreatment width, •Total dose of 17 mg/kg has been given. Pediatric: Loading dose 15 mg/kg IV/IO over 30–60 minutes.
  • 38.
    08/26/17 38 Onset:10–30 minutes.Peak effect: Variable. Duration:3–6 hours. Special considerations •Potent vasodilation and negative inotropic effects. •Hypotension may occur with rapid infusion. •Administer cautiously to patients with cardiac, hepatic, or renal insufficiency; Reduce the dose •Administer cautiously to patients with asthma or digitalis- induced dysrhythmias.
  • 39.
    08/26/17 39 MAGNESIUM SULFATECLASS Electrolyte, anticonvulsant Blocks peripheral neuromuscular transmission by reducing acetylcholine release at the myoneural junction. Lead to reduces muscle contractions Onset: Immediate; Duration: 30 min INDICATIONS •Seizures of eclampsia (toxemia of pregnancy) •Polymorphic VT •Life-threatening ventricular dysrhythmias attributable to digitalis toxicity •Suspected hypomagnesemia •Status asthmatics not responsive to beta-adrenergic drugs CONTRAINDICATIONS Heart block or myocardial damage ADVERSE REACTIONS Facial flushing, Hypotension, Depressed reflexes* Hypothermia ,Reduced heart rate, Circulatory collapse, Respiratory depression*
  • 40.
    08/26/17 40 DRUG INTERACTIONS •Seriouschanges in cardiac function may occur with cardiac glycosides (avoid excess magnesium administration). DOSAGE AND ADMINISTRATION Adult •Seizure activity associated with pregnancy : 1-4 g IV/10m; then 1g/h • Cardiac Arrest : 1–2 g IV/IO over 5 min. • Torsades w/pulse or Hypomagnesemia: 1–2g over 10-30 min IV/IO then 0.5gm –1gm/hr • Status Asthmatics : 1-2 g over 30m ,Repeat the dose on need Pediatric Status asthmaticus 25-50 mg/kg IV/IO (max 2 g) over 30 min
  • 41.
    08/26/17 41 SPECIAL CONSIDERATIONS •Itis recommended that the drug not be administered in the 2 h before delivery . •IV calcium gluconate or calcium chloride should be available as an antagonist to magnesium if needed •Convulsions may occur up to 48 hr after delivery, necessitating continued therapy. •Magnesium must be used with caution in patients with renal failure because it is cleared by the kidneys and can reach toxic levels easily in those patients.
  • 42.
    Case no. 4 60year old man known case of DM brought by family , History of vomiting ,poor oral intake O.E : looks confused and sweaty BP 110/60 , HR 100/m , RR 20/M , RBS 1mmol 08/26/17 42
  • 43.
    08/26/17 43 Dextrose ClassCarbohydrate, antihypoglycemic. Mechanism of action: Rapidly increases serum glucose levels. Short-term osmotic diuresis. Indications : •Hypoglycemia, •Altered level of consciousness, coma of unknown origin, seizure of unknown origin, • Hyperkalemia* Contraindications : Intracranial hemorrhage. Adverse reactions/side effects :Extravasation leads to tissue necrosis., pulmonary edema, hyperglycemia.
  • 44.
    08/26/17 44 Duration ofaction : Onset: Less than 1 minute. Peak effect: Variable. Duration: Variable. Special considerations : •Administer thiamine prior to D 50 in known alcoholic patients. Drug interactions : Sodium bicarbonate, warfarin (Coumadin). Dosage and administration • Adult: 50 ml of 50% solution slow IV push. May be repeated as necessary. •Pediatric: 1 year and older; 4 ml /kg of a 25% solution slow IV/IO push. May be repeated as necessary. •Neonates and infants: 2-4 ml / kg of a 10% solution slow IV push*
  • 45.
    08/26/17 45 Case no.5 34 year old man known case of depression brought by EMS found unresponsive , Agitated . O.E Confused ,Irritable Dilated pupils, Dry skin BP 90/60 , HR 110/m, O2sat 95 %,RR10/m . Blood sugar 7 mmol /L
  • 46.
  • 47.
    08/26/17 47 Sodium BicarbonateClass Systemic hydrogen ion buffer, alkalizing agent. Mechanism of action Buffers metabolic acidosis and lactic acid by reacting with hydrogen ions to form water and carbon dioxide Indications : •Tricyclic antidepressant, aspirin, and phenobarbital overdose. •Metabolic acidosis during cardiac arrest.* •Hyperkalemia .* •crush injuries. * Contraindications : Metabolic and respiratory alkalosis, hypokalemia. Adverse reactions/side effects : Hypernatremia, metabolic alkalosis, necrosis at injection site. Seizures, fluid retention, hypokalemia, electrolyte imbalance, sodium retention, peripheral edema. Drug interactions. •Decreases the effects of benzodiazepines, tricyclic antidepressants. •May deactivate sympathomimetic (dopamine, epinephrine, norepinephrine).
  • 48.
    08/26/17 48 Dosage andadministration •Adult: 1mEq/kg slow IV, IO push may repeat at 0.5 mEq/kg every 10 minutes. •Pediatric:1mEq/kg slow IV, IO push dilute in small children to 4.2% . Onset: Seconds. Peak effect: 1–2 minutes. Duration: 10 minutes
  • 49.
    08/26/17 49 Special considerations •Repeatas needed in tricyclic antidepressant overdose until QRS narrows. •Must be used in conjunction with effective ventilation and chest compressions in cardiac arrest. •Avoid contact with other medications; may precipitate or inactivate them. •Always flush IV line well before and after injecting •Use with caution in patients with CHF and renal disease due to high sodium concentration. •Monitor patient closely for signs and symptoms of fluid overload.
  • 50.
    Case no. 6 68-year-oldwoman presented to the ED with two days of progressive dizziness followed by syncope on the day of presentation. She denied chest pain or dyspnea. She had a history of subarachnoid hemorrhage and hypertension managed with diltiazem.
  • 52.
    08/26/17 52 Atropine SulfateClass Anticholinergic agent. Acts as a competitive antagonist of acetylcholine (ACh) at the muscarinic receptor Increases heart rate in life-threatening Brady dysrhythmias Indications Hemodynamically unstable bradycardia, organophosphate poisoning, nerve agent exposure, RSI in pediatrics, beta blocker or calcium channel blocker overdose. Not likely to be effective for type II second-degree or third degree block Contraindications : Tachycardia, hypersensitivity, narrow-angle glaucoma, hypothermic bradycardia Adverse reactions/side effects Drowsiness, confusion, headache, tachycardia, palpitations, dysrhythmias, nausea, vomiting, pupil dilation, dry mouth/nose/skin, blurred vision, urinary retention, constipation, flushed, hot, dry skin; paradoxical bradycardia when pushed too slowly or when given at low doses.
  • 53.
    08/26/17 53 Drug interactions Effectsenhanced by antihistamines, procainamide, quinidine, antipsychotics, benzodiazepines, and antidepressants. DOSE : • Symptomatic bradycardia 0.5 mg IV ,repeat every 5m maximum dose 3 mg. • Organophosphate poisoning: Extremely large doses may be needed. • Pediatric: : 0.02 mg/kg IV/IO Onset: Immediate. Peak effect: Rapid to 1–2 minutes. Duration: 2–6 Hr Special considerations • Moderate doses may cause pupillary dilation. • Paradoxical bradycardia can occur with doses lower than 0.1 mg.
  • 54.
    08/26/17 54 Calcium GluconateClass Electrolyte. Mechanism of action : Stabilizing the membranes of the cardiac cells •Counteracts the toxicity of hyperkalemia . •Reducing the likelihood of fibrillation Indications: Hyperkalemia, hypocalcemia, hypermagnesemia, beta blocker and calcium channel blocker overdose. Contraindications: Digitalis toxicity *,Hypercalcemia. Adverse reactions/side effects: Syncope, cardiac arrest, dysrhythmia, bradycardia, asystole ,N., V., metallic taste, tissue necrosis at injection site .
  • 55.
    08/26/17 55 Drug interactions •Mayworsen dysrhythmias secondary to digitalis toxicity. •May antagonize the effects of calcium channel blockers. •Do not mix or infuse immediately before or after sodium bicarbonate without intervening flush. Dosage and administration Adult: 10-20ml of 10% calcium gluconate over 10 m. Pediatric: 0.6-1.2 ml/kg 10 % calcium gluconate over 10m . Onset: Immediate. Peak effect: Immediate. Duration: 30m- 2H Special considerations Do not administer by IM or SQ; causes significant tissue necrosis
  • 56.
    08/26/17 56 Case no.7 23 year old man brought by his family founded unresponsive ,cyanotic with shallow breathing vital sign : BP100/60 , PR 56 /m, RR 4/m , O2 sat. 85% RA
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    08/26/17 58 Naloxone HydrochlorideClass Opioid antagonist, antidote. Mechanism of action Competitive inhibition at narcotic receptor sites. Reverses respiratory depression secondary to opiate drugs. Indications •Opiate overdose ; complete or partial reversal of central nervous system and respiratory depression induced by opioids, •Decreased level of consciousness and coma of unknown origin. Narcotic antagonist for the following: Morphine sulfate, Heroin, Hydromorphone ,Methadone, Meperidine , Fentanyl ,Oxycodone Codeine, Propoxyphene.
  • 59.
    08/26/17 59 Special consideration •Use with caution in narcotic-dependent patients. * • Use with caution in neonates of narcotic-addicted mothers.* Adverse reactions/side effects Restlessness,* seizures*, dyspnea, pulmonary edema*, tachycardia, hypertension, dysrhythmias, nausea, vomiting, withdrawal symptoms in opioid-addicted patients, diaphoresis. Drug interactions Incompatible with bisulfite and alkaline solutions.
  • 60.
    08/26/17 60 Dosage andadministration Adult: 0.4–2 mg IM/IV/IO/SQ/ ET/Intranasal (diluted); minimum single dose* recommended. Repeat at 5-minute intervals to a maximum total dose of 10 mg. Pediatric: 0.1 mg/kg/dose IV/IO/IM/SQ every 2 minutes as needed. Maximum total dose of 2 mg. If no response in 10 minutes, administer an additional 0.1 mg/kg/dose. Onset: <2 minutes. Peak effect: Variable. Duration: 30–60 minutes. Special considerations : •Assist ventilations prior to administration to avoid sympathetic stimulation. •Use caution when administering to narcotic addicts (potential violent behavior). • Half-life of naloxone is often shorter than the half-life of narcotics; repeat dosing may be required.
  • 61.
    08/26/17 61 DIAZEPAM CLASSBenzodiazepine Indication •Acute Anxiety States •Acute Alcohol Withdrawal •Skeletal Muscle Relaxation •Seizure Activity •Premedication Before Counter shock Or Transcutaneous Pacing Rapid IV administration may be followed by respiratory depression and excessive sedation, particularly in elderly patients. Onset: (IV) 1-5 min; (IM) 15-30 min Duration: (IV) 15 min-1Hr; (IM) 15min-1Hr
  • 62.
    08/26/17 62 Contraindications •Hypersensitivity tothe drug . •Substance abuse (use with caution) . •Coma (unless the patient has seizures or severe muscle rigidity or myoclonus) •Shock •Central nervous system depression as a result of head injury •Respiratory depression . ADVERSE REACTIONS :Hypotension, Respiratory depression , Ataxia, Confusion, Dizziness ,Drowsiness, Blurred vision DRUG INTERACTIONS •Increase CNS depression with other CNS depressant medications. •Incompatible with most fluids; should be administered into an IV of NS solution. .
  • 63.
    08/26/17 63 DOSAGE ANDADMINISTRATION •Seizure Activity Adult: 5-10 mg over 2m. IV every 10-15 m in prn (max dose: 30 mg) Pediatric: 0.1 -0.2 mg /kg max 5 mg slow IV •Cardioversion or Transcutaneous Pacing Adult: 5-10 m g IV, over 2 min. before procedure SPECIAL CONSIDERATIONS : •Diazepam may cause local venous irritation. • Reduce dose by 50% in elderly patients. • Rectal administration may require higher dose because absorption is incomplete. • Resuscitation equipment should be readily available
  • 64.
    08/26/17 64 Case no.8 28 year old female brought by her family with history of bee sting at home . O.E puffy face, swollen lip and unable to swallow diffuse skin rash, wheezy chest BP 100/60 , HR 110/M , RR 22/M
  • 65.
  • 66.
    08/26/17 66 Epinephrine(Adrenalin) ClassSympathomimetic. Mechanism of action Direct-acting alpha and beta agonist. •Alpha: vasoconstriction. •Beta-1: positive inotropic, chronotropic, and dromotropic effects. •Beta-2: bronchial smooth muscle relaxation and dilation of skeletal vasculature. •Blocks histamine receptors. Indications •Cardiac arrest (asystole, PEA, VF and pulseless VT ), •Symptomatic bradycardia as an alternative infusion to dopamine, •Severe hypotension secondary to bradycardia when atropine and transcutaneous pacing are unsuccessful, •Allergic reaction, anaphylaxis, asthma. Contraindications : Hypertension, hypothermia, pulmonary edema, myocardial ischemia, hypovolemic shock.* Adverse reactions/side effects* Nervousness, restlessness, headache, tremor, pulmonary edema, dysrhythmias, chest pain, hypertension, tachycardia, N,V .
  • 67.
    08/26/17 67 Drug interactions •Potentiatesother sympathomimetics. •Deactivated by alkaline solutions. Dosage and administration Adult: •Anaphylaxis: 0.3 mg-0.5 mg* (1:1,000) IM repeat every 5-10 m . •Cardiac arrest: IV/IO dose: 1 mg (10 mL, 1:10,000 solution) 3–5 minutes during resuscitation. •Profound bradycardia or hypotension: 2–10 µg/min; titrate to patient response. •Higher dose: Higher doses (up to 0.2 mg/kg) may be used for specific indications: (beta blocker or calcium channel blocker overdose).
  • 68.
    08/26/17 68 Pediatric: •Anaphylaxis/severe statusasthmaticus: 0.01 mg/kg (0.01 mL/kg) IM of a 1:1,000 solution (maximum single dose: 0.3 mg). •Cardiac arrest: IV/IO dose: 0.01 mg/kg (0.1 mL/kg) of a 1:10,000 solution every 3–5 minutes during arrest. • Symptomatic bradycardia: IV/IO dose: 0.01 mg/kg (0.01 mL/kg) of a 1:10,000 solution. Onset: Immediate. Peak effect: Minutes. Duration : Several minutes. Special considerations •May cause syncope in asthmatic children. •May increase myocardial oxygen demand. To mix an infusion add 1 mg of epinephrine 1:1,000 to 500 mL D 5 W for a yield of 2 mcg/mL.
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    CRITICAL POINTS • Knowdosages, indications, contraindications and side effects of drugs . • Know concentrations of drugs. • Know what drugs look like at your organization • Read…Read…Read 08/26/17 71
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